// Get from db
// Store in easy to use format

$dbcompanyname = ''; 
$dbfname = '';
$dblname = '';
$dbaddr1 = '';
$dbaddr2 = '';
$dbcity = '';
$dbstate = '';
$dbzip = '';
$dbcountry = '';
$dbphone = '';
$dbext = '';
$dbfax = '';
$dbemail = '';
echo '<script src="assets/snippets/shoppingCart/md5.js" type="text/javascript"></script>';
echo '<div id="CheckoutFormDiv" style="width: 95%; ">';
echo '<div id="BillingInfoTitle" style="width:100%; height: 25px; padding-top: 5px; padding-left: 10px; background-color: #497AFF; color: #FFF; font-size: 16px; font-weight: bold;">Sign Up for an Account</div>';

echo '<div id="BillingInfoDetail" style="width: 98%; height: 420px; padding: 10px; background-color: #E3E8E8;">';

echo '<div id="usernamefield" style="width: 83%; padding-top: 10px; float:right; "><input tabindex="1" type="text" id="username" size="15" onChange="checkusername();" value="'. $dbcompanyname . '" /></div>';
echo '<div id="usernamelabel" style="width: 8%; padding-top: 10px; float:left; color: #54534C; font-size: 14px; font-weight: bold; padding-right: 10px">Username:*</div>';

echo '<div id="passwordfield" style="width: 83%; padding-top: 10px; float:right; "><input tabindex="2" type="password" id="password" size="15" value="'. $dbcompanyname . '" /></div>';
echo '<div id="passwordlabel" style="width: 8%; padding-top: 10px; float:left; color: #54534C; font-size: 14px; font-weight: bold; padding-right: 10px">Password:*</div>';

echo '<div id="confirmpasswordfield" style="width: 83%; padding-top: 10px; float:right; "><input tabindex="3" type="password" id="confirmpassword" size="15" value="'. $dbcompanyname . '" /></div>';
echo '<div id="confirmpasswordlabel" style="width: 8%; padding-top: 10px; float:left; color: #54534C; font-size: 14px; font-weight: bold; padding-right: 10px">Confirm:*</div><br />';

echo '<div id="emailfield" style="width: 83%; float:right; padding-top: 10px; "><input tabindex="4" type="text" id="email" size="35" onChange="checkemail();" value="'. $dbemail . '" /></div>';
echo '<div id="emaillabel" style="width: 8%; float:left; color: #54534C; padding-top: 10px; font-size: 14px; font-weight: bold;">Email:*</div>';

echo '<div id="companyfield" style="width: 83%; padding-top: 10px; float:right; "><input tabindex="5" type="text" id="company" size="35" value="'. $dbcompanyname . '" /></div>';
echo '<div id="companylabel" style="width: 8%; padding-top: 10px; float:left; color: #54534C; font-size: 14px; font-weight: bold; padding-right: 10px">Company:</div>';

echo '<div id="lnamefield" style="width: 25%; float:right; padding-top: 10px; padding-right: 20px;"><input tabindex="7" type="text" id="lname" value="'. $dblname . '"/></div>';
echo '<div id="lnamelabel" style="width: 16%; float:right; padding-top: 10px; color: #54534C; font-size: 14px; font-weight: bold; padding-right: 10px">Last Name:*</div>';
echo '<div id="fnamefield" style="width: 25%; float:right; padding-top: 10px; padding-right: 55px;"><input tabindex="6" type="text" id="fname" value="'. $dbfname . '"/></div>';
echo '<div id="fnamelabel" style="width: 16%; float:left;  padding-top: 10px; color: #54534C; font-size: 14px; font-weight: bold;">First Name:*</div>';

echo '<div id="addr1field" style="width: 25%; padding-top: 10px; float:right; padding-right: 292px;"><input tabindex="8" type="text" id="addr1" size="41" value="'. $dbaddr1 . '"/></div>';
echo '<div id="addr1label" style="width: 15%; padding-top: 10px; float:left;  color: #54534C; font-size: 14px; font-weight: bold;">Address:*</div>';
echo '<div id="addr2field" style="width: 25%; padding-top: 10px; float:right; padding-right: 292px;"><input tabindex="9" type="text" id="addr2" size="41" value="'. $dbaddr2 . '"/></div>';
echo '<div id="addr2label" style="width: 15%; padding-top: 10px; float:left;  color: #54534C; font-size: 14px; font-weight: bold;">Address 2:</div>';

echo '<div id="zipfield" style="width: 10%; padding-top: 10px; float:right; padding-right: 40px;"><input tabindex="12" type="text" size="5" id="zip" value="'. $dbzip . '"/></div>';
echo '<div id="ziplabel" style="width: 10%; padding-top: 10px; float:right; color: #54534C; font-size: 14px; font-weight: bold; ">Zip:*</div>';
echo '<div id="statefield" style="width: 4%; padding-top: 10px; float:right; padding-right: 60px;"><input tabindex="11" type="text" size="5" id="state" value="'. $dbstate . '"/></div>';
echo '<div id="statelabel" style="width: 10%; padding-left: 10px; padding-top: 10px; float:right; color: #54534C; font-size: 14px; font-weight: bold; padding-right: 10px;">State:*</div>';
echo '<div id="cityfield" style="width: 10%; padding-top: 10px; float:right; padding-right: 105px;"><input tabindex="10" type="text" id="city" value="'. $dbcity . '"/></div>';
echo '<div id="citylabel" style="width: 9%; padding-top: 10px; float:left;  color: #54534C; font-size: 14px; font-weight: bold;">City:*</div>';

echo '<div id="countryfield" style="width: 83%; padding-top: 10px; float:right; ">
             <select size="1" id="country" name="country" tabindex="13" style="width:300px">
                <option selected value="223">United States</option>
                <option value="1">Afghanistan</option>
                <option value="2">Albania</option>
                <option value="3">Algeria</option>
                <option value="4">American Samoa</option>
                <option value="5">Andorra</option>
                <option value="6">Angola</option>
                <option value="7">Anguilla</option>
                <option value="8">Antarctica</option>
                <option value="9">Antigua and Barbuda</option>
                <option value="10">Argentina</option>
                <option value="11">Armenia</option>
                <option value="12">Aruba</option>
                <option value="13">Australia</option>
                <option value="14">Austria</option>
                <option value="15">Azerbaijan</option>
                <option value="16">Bahamas</option>
                <option value="17">Bahrain</option>
                <option value="18">Bangladesh</option>
                <option value="19">Barbados</option>
                <option value="20">Belarus</option>
                <option value="21">Belgium</option>
                <option value="22">Belize</option>
                <option value="23">Benin</option>
                <option value="24">Bermuda</option>
                <option value="25">Bhutan</option>
                <option value="26">Bolivia</option>
                <option value="27">Bosnia and Herzegowina</option>
                <option value="28">Botswana</option>
                <option value="29">Bouvet Island</option>
                <option value="30">Brazil</option>
                <option value="31">British Indian Ocean Territory</option>
                <option value="32">Brunei Darussalam</option>
                <option value="33">Bulgaria</option>
                <option value="34">Burkina Faso</option>
                <option value="35">Burundi</option>
                <option value="36">Cambodia</option>
                <option value="37">Cameroon</option>
                <option value="38">Canada</option>
                <option value="39">Cape Verde</option>
                <option value="40">Cayman Islands</option>
                <option value="41">Central African Republic</option>
                <option value="42">Chad</option>
                <option value="43">Chile</option>
                <option value="44">China</option>
                <option value="45">Christmas Island</option>
                <option value="46">Cocos (Keeling) Islands</option>
                <option value="47">Colombia</option>
                <option value="48">Comoros</option>
                <option value="49">Congo</option>
                <option value="50">Cook Islands</option>
                <option value="51">Costa Rica</option>
                <option value="52">Cote D&#39;Ivoire</option>
                <option value="53">Croatia</option>
                <option value="54">Cuba</option>
                <option value="55">Cyprus</option>
                <option value="56">Czech Republic</option>
                <option value="57">Denmark</option>
                <option value="58">Djibouti</option>
                <option value="59">Dominica</option>
                <option value="60">Dominican Republic</option>
                <option value="61">East Timor</option>
                <option value="62">Ecuador</option>
                <option value="63">Egypt</option>
                <option value="64">El Salvador</option>
                <option value="65">Equatorial Guinea</option>
                <option value="66">Eritrea</option>
                <option value="67">Estonia</option>
                <option value="68">Ethiopia</option>
                <option value="69">Falkland Islands (Malvinas)</option>
                <option value="70">Faroe Islands</option>
                <option value="71">Fiji</option>
                <option value="72">Finland</option>
                <option value="73">France</option>
                <option value="74">France, Metropolitan</option>
                <option value="75">French Guiana</option>
                <option value="76">French Polynesia</option>
                <option value="77">French Southern Territories</option>
                <option value="78">Gabon</option>
                <option value="79">Gambia</option>
                <option value="80">Georgia</option>
                <option value="81">Germany</option>
                <option value="82">Ghana</option>
                <option value="83">Gibraltar</option>
                <option value="84">Greece</option>
                <option value="85">Greenland</option>
                <option value="86">Grenada</option>
                <option value="87">Guadeloupe</option>
                <option value="88">Guam</option>
                <option value="89">Guatemala</option>
                <option value="90">Guinea</option>
                <option value="91">Guinea-bissau</option>
                <option value="92">Guyana</option>
                <option value="93">Haiti</option>
                <option value="94">Heard and Mc Donald Islands</option>
                <option value="95">Honduras</option>
                <option value="96">Hong Kong</option>
                <option value="97">Hungary</option>
                <option value="98">Iceland</option>
                <option value="99">India</option>
                <option value="100">Indonesia</option>
                <option value="101">Iran (Islamic Republic of)</option>
                <option value="102">Iraq</option>
                <option value="103">Ireland</option>
                <option value="104">Israel</option>
                <option value="105">Italy</option>
                <option value="106">Jamaica</option>
                <option value="107">Japan</option>
                <option value="108">Jordan</option>
                <option value="109">Kazakhstan</option>
                <option value="110">Kenya</option>
                <option value="111">Kiribati</option>
                <option value="112">Korea, Democratic People&#39;s Republic of</option>
                <option value="113">Korea, Republic of</option>
                <option value="114">Kuwait</option>
                <option value="115">Kyrgyzstan</option>
                <option value="116">Lao People&#39;s Democratic Republic</option>
                <option value="117">Latvia</option>
                <option value="118">Lebanon</option>
                <option value="119">Lesotho</option>
                <option value="120">Liberia</option>
                <option value="121">Libyan Arab Jamahiriya</option>
                <option value="122">Liechtenstein</option>
                <option value="123">Lithuania</option>
                <option value="124">Luxembourg</option>
                <option value="125">Macau</option>
                <option value="126">Macedonia, The Former Yugoslav Republic of</option>
                <option value="127">Madagascar</option>
                <option value="128">Malawi</option>
                <option value="129">Malaysia</option>
                <option value="130">Maldives</option>
                <option value="131">Mali</option>
                <option value="132">Malta</option>
                <option value="133">Marshall Islands</option>
                <option value="134">Martinique</option>
                <option value="135">Mauritania</option>
                <option value="136">Mauritius</option>
                <option value="137">Mayotte</option>
                <option value="138">Mexico</option>
                <option value="139">Micronesia, Federated States of</option>
                <option value="140">Moldova, Republic of</option>
                <option value="141">Monaco</option>
                <option value="142">Mongolia</option>
                <option value="143">Montserrat</option>
                <option value="144">Morocco</option>
                <option value="145">Mozambique</option>
                <option value="146">Myanmar</option>
                <option value="147">Namibia</option>
                <option value="148">Nauru</option>
                <option value="149">Nepal</option>
                <option value="150">Netherlands</option>
                <option value="151">Netherlands Antilles</option>
                <option value="152">New Caledonia</option>
                <option value="153">New Zealand</option>
                <option value="154">Nicaragua</option>
                <option value="155">Niger</option>
                <option value="156">Nigeria</option>
                <option value="157">Niue</option>
                <option value="158">Norfolk Island</option>
                <option value="159">Northern Mariana Islands</option>
                <option value="160">Norway</option>
                <option value="161">Oman</option>
                <option value="162">Pakistan</option>
                <option value="163">Palau</option>
                <option value="164">Panama</option>
                <option value="165">Papua New Guinea</option>
                <option value="166">Paraguay</option>
                <option value="167">Peru</option>
                <option value="168">Philippines</option>
                <option value="169">Pitcairn</option>
                <option value="170">Poland</option>
                <option value="171">Portugal</option>
                <option value="172">Puerto Rico</option>
                <option value="173">Qatar</option>
                <option value="174">Reunion</option>
                <option value="175">Romania</option>
                <option value="176">Russian Federation</option>
                <option value="177">Rwanda</option>
                <option value="178">Saint Kitts and Nevis</option>
                <option value="179">Saint Lucia</option>
                <option value="180">Saint Vincent and the Grenadines</option>
                <option value="181">Samoa</option>
                <option value="182">San Marino</option>
                <option value="183">Sao Tome and Principe</option>
                <option value="184">Saudi Arabia</option>
                <option value="185">Senegal</option>
                <option value="186">Seychelles</option>
                <option value="187">Sierra Leone</option>
                <option value="188">Singapore</option>
                <option value="189">Slovakia (Slovak Republic)</option>
                <option value="190">Slovenia</option>
                <option value="191">Solomon Islands</option>
                <option value="192">Somalia</option>
                <option value="193">South Africa</option>
                <option value="194">South Georgia and the South Sandwich Islands</option>
                <option value="195">Spain</option>
                <option value="196">Sri Lanka</option>
                <option value="197">St. Helena</option>
                <option value="198">St. Pierre and Miquelon</option>
                <option value="199">Sudan</option>
                <option value="200">Suriname</option>
                <option value="201">Svalbard and Jan Mayen Islands</option>
                <option value="202">Swaziland</option>
                <option value="203">Sweden</option>
                <option value="204">Switzerland</option>
                <option value="205">Syrian Arab Republic</option>
                <option value="206">Taiwan</option>
                <option value="207">Tajikistan</option>
                <option value="208">Tanzania, United Republic of</option>
                <option value="209">Thailand</option>
                <option value="210">Togo</option>
                <option value="211">Tokelau</option>
                <option value="212">Tonga</option>
                <option value="213">Trinidad and Tobago</option>
                <option value="214">Tunisia</option>
                <option value="215">Turkey</option>
                <option value="216">Turkmenistan</option>
                <option value="217">Turks and Caicos Islands</option>
                <option value="218">Tuvalu</option>
                <option value="219">Uganda</option>
                <option value="220">Ukraine</option>
                <option value="221">United Arab Emirates</option>
                <option value="222">United Kingdom</option>
                <option value="224">United States Minor Outlying Islands</option>
                <option value="225">Uruguay</option>
                <option value="226">Uzbekistan</option>
                <option value="227">Vanuatu</option>
                <option value="228">Vatican City State (Holy See)</option>
                <option value="229">Venezuela</option>
                <option value="230">Viet Nam</option>
                <option value="231">Virgin Islands (British)</option>
                <option value="232">Virgin Islands (U.S.)</option>
                <option value="233">Wallis and Futuna Islands</option>
                <option value="234">Western Sahara</option>
                <option value="235">Yemen</option>
                <option value="236">Yugoslavia</option>
                <option value="237">Zaire</option>
                <option value="238">Zambia</option>
                <option value="239">Zimbabwe</option>

</select><br />
</div>';

echo '<div id="countrylabel" style="width: 8%; padding-top: 10px; float:left; color: #54534C; font-size: 14px; font-weight: bold; padding-right: 10px; padding-bottom: 5px; ">Country:*</div>';

echo '<div id="blankfield" style="width: 10%; padding-top: 10px; float:right; padding-right: 18px;"></div>';
echo '<div id="blanklabel" style="width: 10%; padding-top: 10px; float:right; color: #54534C; font-size: 14px; font-weight: bold; "></div>';
echo '<div id="extfield" style="width: 4%; padding-top: 10px; float:right; padding-right: 60px;"><input tabindex="15" type="text" size="5" id="ext" value="'. $dbext .'"></div>';
echo '<div id="extlabel" style="width: 10%; padding-left: 10px; padding-top: 10px; float:right; color: #54534C; font-size: 14px; font-weight: bold; padding-right: 10px;">Ext:</div>';
echo '<div id="phonefield" style="width: 10%; padding-top: 10px; float:right; padding-right: 100px;"><input tabindex="14" type="text" id="phone" value="'. $dbphone . '"/></div>';
echo '<div id="phonelabel" style="width: 9%; padding-top: 10px; float:left;  color: #54534C; font-size: 14px; font-weight: bold;">Phone:*</div>';

echo '<div id="faxfield" style="width: 48%; padding-right: 178px; padding-top: 10px; float:right; "><input tabindex="16" type="text" id="fax" value="'. $dbfax . '"/></div>';
echo '<div id="faxlabel" style="width: 10%; padding-top: 10px; float:left;  color: #54534C; font-size: 14px; font-weight: bold;">Fax:</div>';

echo '</div>';

echo '<br />';
echo '</div>';
echo '<br />';
